Home NRC Library Document Collections Events, Reports Associated with Event Notification Reports 2019

Event Notification Report for September 23, 2019

U.S. Nuclear Regulatory Commission
Operations Center

Event Reports For
9/20/2019 - 9/23/2019

** EVENT NUMBERS **

Agreement State	Event Number: 54274
Rep Org: ILLINOIS EMERGENCY MGMT. AGENCY Licensee: AMERICAS STYRENCS LLC Region: 3 City: CHANNAHON State: IL County: WILL License #: IL-02375-01 Agreement: Y Docket: NRC Notified By: C GIBB VINSON HQ OPS Officer: BRIAN LIN	Notification Date: 09/13/2019 Notification Time: 09:36 [ET] Event Date: 09/10/2019 Event Time: 00:00 [CDT] Last Update Date: 09/13/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): DIANA BETANCOURT-ROLDAN (R3DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - STUCK SHUTTER

The following was received by the State of Illinois via email:

"The Radiation Safety Officer for Americas Styrencs, LLC, called to report that on September 10, 2019, they were conducting a routine six month shutter check on a Texas Nuclear Model 5180A device and determined that the shutter was stuck in the open position. The device is 40 years old, and it originally contained 2 Curies of Cs-137. The gauge is located on a vessel which is still in active use and is exposed to ambient weather conditions. The gauge is located approximately 10 feet overhead and the beam path is not a routine work location for day-to-day operations. They will contact Thermo MeasureTech to schedule service on the device and apprise the Illinois Emergency Management Agency (Agency) on the service date. Since this device operates continuously, it will continue to function and not interrupt their operations. An Agency inspector arrived on the scene on the same day to confirm that the device was in a safe configuration for continued operations."

Illinois Item Number: IL190028

Non-Agreement State	Event Number: 54275
Rep Org: MATERIALS TESTING, INC Licensee: MATERIALS TESTING, INC Region: 1 City: NEW HAVEN State: CT County: License #: 06-199-0901 Agreement: N Docket: NRC Notified By: WILLIAM SOUCY HQ OPS Officer: OSSY FONT	Notification Date: 09/13/2019 Notification Time: 11:32 [ET] Event Date: 09/12/2019 Event Time: 11:30 [EDT] Last Update Date: 09/13/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 30.50(b)(2) - SAFETY EQUIPMENT FAILURE	Person (Organization): DONNA JANDA (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

DAMAGED DENSITY GAUGE

The following is a synopsis of information received via phone:

On September 12, 2019, at approximately 1130 EDT, a Humboldt gauge (Model 5001C; S/N 3267), containing 10 mCi of Cs-137 and a 40 mCi Am-241/Be source, was damaged during a field inspection. The inspector notified the radiation safety officer (RSO) and informed him that the source was retracted at the time and the source was not damaged. The RSO instructed the inspector to place the device in the carrying case and return it to him at the office. No survey of the device was performed prior to removal from the job site.

Once the device was at the office, the RSO performed a swipe test and will be sending it to Humboldt. The RSO was also going to notify the device manufacturer of the damaged gauge. No exposure is expected but personnel dosimetry badge was sent for processing.

Fuel Cycle Facility	Event Number: 54279
Facility: GLOBAL NUCLEAR FUEL - AMERICAS RX Type: URANIUM FUEL FABRICATION Comments: LEU CONVERSION (UF6 TO UO2) LEU FABRICATION LWR COMMERICAL FUEL Region: 2 City: WILMINGTON State: NC County: NEW HANOVER License #: SNM-1097 Docket: 07001113 NRC Notified By: PHILLIP OLLIS HQ OPS Officer: OSSY FONT	Notification Date: 09/13/2019 Notification Time: 14:47 [ET] Event Date: 09/12/2019 Event Time: 16:40 [EDT] Last Update Date: 09/13/2019
Emergency Class: NON EMERGENCY 10 CFR Section: PART 70 APP A (c) - OFFSITE NOTIFICATION/NEWS REL	Person (Organization): FRANK EHRHARDT (R2DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

CONCURRENT REPORT FOR FIRE ALARM MAINTENANCE

"At 1640 (EDT) on September 12, 2019, the New Hanover County Deputy Fire Marshall was notified, per State code requirements, that the fire alarm system encompassing the Fuel Manufacturing Operation (FMO) will be taken offline for planned maintenance. The system was taken offline at approximately 0800 on September 13, 2019. Compensatory measures were enacted. The system was returned to service at approximately 1335 on September 13, 2019. Because the New Hanover County Deputy Fire Marshall was notified, a concurrent notification to the NRC Operations Center is being made per 10 CFR 70, Appendix A(c)."

The NRC Region, as well as the North Carolina Radioactive Materials Branch, will be notified.

Agreement State	Event Number: 54280
Rep Org: MA RADIATION CONTROL PROGRAM Licensee: MASSACHUSETTS GENERAL HOSPITAL Region: 1 City: BOSTON State: MA County: License #: 60-0055 Agreement: Y Docket: NRC Notified By: SZYMON MUDREWICZ HQ OPS Officer: OSSY FONT	Notification Date: 09/13/2019 Notification Time: 16:28 [ET] Event Date: 09/11/2019 Event Time: 00:00 [EDT] Last Update Date: 09/13/2019
Emergency Class: NON EMERGENCY 10 CFR Section: AGREEMENT STATE	Person (Organization): DONNA JANDA (R1DO) NMSS_EVENTS_NOTIFICATION (EMAIL)

Event Text

AGREEMENT STATE REPORT - MISADMINISTRATION OF HIGH DOSE RATE THERAPY

The following was received via email from the Massachusetts Department of Public Health - Radiation Control Program (the Agency):

"On 09/13/19, a medical event was reported by Massachusetts General Hospital (MGH) (the licensee) involving the medical misadministration of HDR [high dose rate] therapy. The 59 year-old patient involved received dose to unintended tissue exceeding 50 percent of the prescribed dose defined in the written directive. The prescribed dose was 5.5 Gy over 5 fractions for a total of 27.5 Gy to the cervix. The therapy was performed using a Syeb-Neblett Template and 6 catheters including 1 tandem. The patient ultimately received the full intended dose to the tumor (high risk- CTV [clinical target volume]) and per the licensee there was no overdose to any critical structures including bladder, rectum, or bowel. A small region of the surface of the right vaginal wall (approximately 1 cm) did inadvertently receive 16.5 Gy due to the wrong treatment distances being entered into the treatment planning system for 2 of the 7 catheters by the physicist. The patient is not expected to be at an increased risk for toxicity due to this error. Both the patient and referring physician were immediately notified upon discovery. Licensee to submit written report within 15 days of discovery date. The Agency considers this event to be open and pending investigation."

A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.

Power Reactor	Event Number: 54287
Facility: FARLEY Region: 2 State: AL Unit: [] [2] [] RX Type: [1] W-3-LP,[2] W-3-LP NRC Notified By: BLAKE MITCHELL HQ OPS Officer: JEFF HERRERA	Notification Date: 09/21/2019 Notification Time: 10:28 [ET] Event Date: 09/21/2019 Event Time: 08:00 [CDT] Last Update Date: 09/21/2019
Emergency Class: NON EMERGENCY 10 CFR Section: 50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL 50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION	Person (Organization): BRIAN BONSER (R2DO)

Unit

SCRAM Code

RX Crit

Initial PWR

Initial RX Mode

Current PWR

Current RX Mode

M/R

100

Power Operation

Hot Standby

Event Text

MANUAL TRIP DUE TO REACTOR COOLANT PUMP VIBRATION ALARM

"At 0800 [CDT], with Unit 2 in Mode 1 at 100 percent [power], the reactor was manually tripped due to elevated vibration indication on the 2C reactor coolant pump exceeding annunciator response procedure trip criteria. The trip was not complex, with all systems responding normally post trip. Auxiliary Feedwater (AFW) auto actuated as expected following the manual reactor trip.

"Operations responded and stabilized the plant. Decay heat is being removed via the use of AFW and subsequent steaming of the steam generators to the main condenser.

"Due to the Reactor Protection System actuation while critical, this event is being reported as a four-hour, non-emergency notification per 10 CFR 50.72(b(2)(iv)(B). In addition, this event report is being reported as an eight-hour non-emergency notification per 10 CFR50.72(B)(3)(iv)(A) for a specified system actuation.

"There was no impact on the health and safety of the public or plant personnel. The NRC resident inspector has been notified."

Farley reported that there was no increase in containment unidentified leakage or fluctuations with RCP seal flow during this event.

Page Last Reviewed/Updated Wednesday, March 24, 2021